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19 May 2012
by Andrew Schutzbank and John G. Norman

Planning in the Clinic (Part 2 of 2)

In the earliest days of ICIS planning, stakeholders and members of the product and engineering teams noticed affinities between our ideal Electronic Medical Record (EMR) system and the project planning systems used in software and design.

We’d like to take some time to talk about these affinities with one of our stakeholders and co-designers of ICIS, Dr. Andrew Schutzbank, MD, MPH. Andrew blogs at www.schutzblog.com, and recently won a “Costs of Care” award for his story regarding how pharmaceutical cost-shifting prevented him from discharging a patient from the hospital.

Q. You’ve taken a special interest in gaming in medical software innovation. Where is that going to take us?

A. At the guidance of our awesome product manager, Jess Kadar, I have been reading Jane McGonigal’s book Reality is Broken. Everyone should read it (parent, doctor, gamer, non-gamer, patient . . .) because it portends the future. Much of my thinking about why I like games comes from her work and her collection of other’s work. Gaming is defined as voluntarily overcoming unnecessary obstacles. Involuntarily overcoming necessary obstacles is called work.

The key then is to overcoming the drudgery of health care by making the work of health care fun. One of the best ways of doing this is socializing our health work. Whether through competition, leader boards, bragging, sharing, storytelling or just keeping each other up to date, there is tremendous power in games. We borrow this from Counterstrike and TF2 and Starcraft. However, what mostly fails is that the underlying game mechanics – taking pills, seeing doctors, getting mammograms – are not only not fun, but highly unpleasant. Starcraft was fun before it became the national sport of Korea. One could argue that repeatedly clicking buttons is not fun, but that is an oversimplification on what makes games games.

I think health care gaming is in its infancy because it is hard to design a game to motivate you to do something that you should already be motivated to do. Who doesn’t want to be in shape and healthy? And yet so few of us are. To try and solve that problem, early health game designers have given away a chance to win an iPad, or a trip to Aruba, or points towards purchases, effectively paying people via games to be helpful. While I think there are important ties between financial and health motivation (mostly that we give up our health for money in the form of poor/quick eating, deferred exercise and missed sleep), these games miss something important. Perhaps, getting back to the social nature of gaming, we need to reward people for getting each other healthy. I might eat a doughnut instead of winning game points, but there is no way in hell I am going to let you eat a doughnut instead of me winning game points.

Another component of non-medical games is that they are amazing at interface design. Many applications just have awful design, making you bend to the will of the designer. Not games. There is no other medium I can think of that so seamlessly sends so much data the way of the user, and has the user begging for more. There are plenty of games with bad interfaces, usually crowding the dustbins of Targets and Walmarts: I just cannot remember playing them (for very long). Contrast this with most medical software, which is just atrocious. I feel like EMR designers secretly hate doctors and wish to torture them, one check box click at a time. There is no way a game would be seriously released (and purchased!) in the sad interface state of so much medical software.

As a disclaimer I have always loved games. Since ColecoVision all the way through modern PC gaming, coming of age during the golden age of SNES RPGs, family board games (the brutal national sport of the Schutzbank household), endless chess matches with my dad (I only have 4 wins in ~26 years), pinball, etc., I have been hooked. I love the meditative state I enter while playing, the opportunity to overcome challenges, experience a story, improve skill, spend active time together with others and simply kick ass.

A. To quote Jess Kadar again: “You cannot create software to do your job for you. To write software to solve a problem, you have to know how to solve the problem.” Doctors are pretty bad at care coordination. Non-docs are even worse. Why would we think that people who either don’t coordinate care, or do it poorly, would be able to write software that makes it easy? Good words describing good processes precede good software. We have none of the above. How do you know? Just ask 4 doctors what care coordination is and expect 6 answers.

Q. They also claim “current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).” Can you describe some concrete cases where the EMR’s provision for what is billable has resulted in information loss in care coordination?

A. Every time something is documented? That is probably a glib answer to a serious question. Docs started writing notes to document interactions with patients, to communicate the day’s meeting to colleagues, future selves and lawyers. Not terrible, but patients undergo diseases and care continuously. We have hard-coded a discrete method for dealing with continuous problems. Unfortunately the note is just not good enough of technology to handle reality.

Writing a note in a modern EMR is actually a game! Like a perverse version of high stakes Yahtzee, I have to satisfy a number of categories in a number of columns to increase my note score ($). This results in multiple ways of cheating the game – check boxes, templates, copy/pasted text carried from previous notes, words/sentences added as flourish like “All other Review of Systems negative” to score points in the game the easy way. Not that we didn’t do the work, but it is hard enough to ask all of the damn questions, then write down that you did, then write down the answers, then try and make any sense of it. This really is not EMRs fault, it is actually the fault of regulators/payors abstracting what was once a research tool (the E&M code sheet) and turning into a torture device. I will try and withhold my comments on top-down bureaucratized medicine, but the billing sheet is a perfect example.

Care coordination is all about finesse. Calling a patient twice. Emailing a doctor buddy to get someone in earlier. Recognizing just after the patient left that what you just explained did not register with them despite their assurances, or even worse, remember to do something extra. Care coordination is about communication, influence, relationship building, trust and follow through. It is really hard to build software to do that, only to support the human activity. The more I think about medical records, they are ideally a great combination of a CRM and Project management tool—where each patient is both a client and a project.